#183 | Group B Strep: Screening, Risks, Protocols, Problems and Alternatives

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

GBS is it's a very important topic for a few reasons. First of all, if you're early in pregnancy, you're not thinking about it. But around 3536 weeks, about a third of women are going to be informed that they are GBS positive, and may feel quite overwhelmed because they didn't see it coming. They don't understand it. They don't know what it is what decisions to make around it. Is it dangerous? Are there protocols to follow or to avoid? So we'll be getting into all of that. The other reason this episode took quite a while to put together is that we've put many, many hours of research into it because there are a lot of studies around GBS, it's just a lot of them don't agree with each other. And the data is different from country to country. So we had to tease out the data that was incongruent with what some of the other things were showing, and we had to number crunch a little bit to compile some of the information for you. And we hope we've put it together in a very logical, succinct format. What do you think, Trisha, you think we are going to pull that off? It was break, we're gonna, we're, I think we're gonna have a really informative, great discussion around it. And women are going to hear a lot of things that they absolutely will not hear from their medical provider. So it is going to be very valuable. But I think just the point about the studies to is important to say that most of the actual research was done way long ago, many years ago, and there isn't a lot of recent research and there really, there is really no randomized controlled trials of recent and that's the gold standard of research. So we don't actually have good modern day research on GBs. So we should begin probably by explaining what GBS is, let's do that. But before we do, let's tell everyone that we have two versions of this episode today a regular and an extended version. There are two ways to get the extended version you can subscribe on Apple podcasts. And if you already subscribed to Apple than the extended version is the one you're listening to right now automatically. And if you don't have Apple or prefer not to use Apple, head over to patreon.com/down to birth show. Patreon is P A T R e o n we'll put it in the show notes. And when you get to Patreon, you'll see that at no extra charge, you'll have access to all of our extended episodes ever, like our monthly extended q&a days, and Downloadables. And we keep adding more good stuff there all the time. Now you might be wondering what's covered in each version? So in this regular or baseline version of the episode, we will be covering what GBS is how its screened. What are the risk factors for testing positive? How effective are the antibiotics, risks to not taking the antibiotics? And finally, what are the risk factors to a baby and tracting GBS because it is the number one risk to vaginally birth babies. So that's important as well. And that's what we'll be covering in the regular version. Go ahead.

Not only is it just the number one risk, but it is the leading cause of infant morbidity and mortality in vaginal birthing women still today, right?

Yeah. So and then in the extended version, and we'll get into this I guess later when we're wrapping up this part of the episode but we're gonna get into like, are there ways to pass the test so that you don't test positive X pass? says a funny word in that, in that context are the ways to get a negative result on the test. Is that a good idea? What do you need to know if you're looking into doing that? If you treat your GBS naturally, can you skip the antibiotics, alternative protocols, we'll also be talking about the effects of the antibiotics on you or your baby, why some women declined the antibiotics. And if you do opt for them, what you can do to basically restore the microbiome in yourself or your baby after the birth? Oh, is there a rapid test? How effective is it? It's actually quite effective. But we're going to talk about what to be aware of if you're interested in the rapid test. And what if you're having a plan to zerion birth? Is it all necessary? And what if you're having a home birth and test positive with TPS? Does that impact anything? And then finally, our thoughts on the universal versus the risk based approach? So we're gonna get much deeper into this, but we're going to make sure everyone has all of the really basic important information. So Trisha with that, if you're willing, well, you just start with just what what GBS is and how it's screened.

Sure thing. Alright, so what is GBS or group B strep. It stands for Group B streptococcus. It's also known as Group B strep or GBS is most commonly how people are going to hear it referenced. It is one of many trillions of organisms that inhabit the human intestinal tract, vagina and rectum. It actually inhabits the bladder as well. At any given moment, in any population, generally, about a third of women are colonized with this bacteria. It's not harmful to a woman in general, although it can cause UTIs, but urinary tract infections for some people. But in general, it's not harmful to be a carrier of it and you can be a carrier of it at some points in your life and you can be a non carrier carrier of it at other points and throughout your just a single pregnancy. You can have GBS at one point and not at another point. Whether or not you test positive has a lot to do with your colonization count. So if GBS is a really prevalent bacteria in your vagina or rectum, you're more likely to test positive if it's just very minimal, you're less likely to test positive. So the risk is to your baby, not to the mother really, very little risk to the mother. And the risk is that there can be a direct transfer of the GBS bacteria from mother to baby typically after water breaks. Because the most common way that babies are infected by GBS is that the bacteria ascends from the vagina into the uterus after the water bag of waters is broken. You no longer have that protective seal and the baby as they're breathing in utero as babies do, they can inhale some of the GBS bacteria, it can get into their lungs and now they have potential risk of systemic infection. The other way that babies can get infected from it is through coming through the birth canal. As they come through the birth canal, that bacteria gets on their skin, and those babies are very likely to be colonized with GBs but that does not mean that they're going to be infected with GBs and most of the time, when babies get it on their skin. They don't actually get infected. The most common way for babies to get infected and sick with GBS is through the ascending infection through the uterus and into the lungs.

Question for you? Yes, you made a passing comment that there's very little risk to the mother. What's the risk to the mother? If even if it's almost nothing? What is it? I never heard of any risk to the urinary tract infection? Oh, I see. So that's the extent of it. Yeah. Okay. Yep. Okay.

So as of 2020, the American College of Obstetricians and Gynecologists. ACOG states that the best time to test for GBS is between 36 and 37 weeks. This is a little bit different than the CDC, which has said in the past 35 to 37 weeks. But because we know that women tend to go into labor after 40 weeks average testing at 35 weeks, the tests are only valid for about five weeks. So if you tested 35 weeks and you got to 41 weeks your test is no longer valid. So they've moved the dates out a little bit further to testing between 37 and 3036 and 37 weeks so that if you are still pregnant at 42 weeks, your test is still likely to be valid.

I'm going to have to jump in again. So when it all these years when women have been tested at 35 and 36 weeks, a lot of them did go to 4142 and I've never seen a provider willing to retest. So if everyone and you agree right most likely they will not retest, they'll still just consider you positive if they'd rather you. But what the data shows is that the test only holds for about five weeks. So if you're colorized, meaning that you are likely to have the same result within a five week period, and you're not necessarily likely to get, so let's get into that, because that might not make sense yet, to everyone listening, if they haven't heard of this before, so shall I do want to church. So basically, just to back up and repeat a little bit of what Tricia just said, For some women, they could have 10 babies, and they will never test positive, because they have such a low amount of GBS in their system, they will just always get a negative result. Whereas some women, if they have numerous babies, they will test positive sometimes, and they'll test negative sometimes. And what's important to understand is when you get your test, first of all, whatever the result is, that is how you will be treated at birth. If it's negative, this is not going to come up again. If it's positive, it I have never seen anyone able to evade that diagnosis to say, well test me again and 42 weeks now, it just seems like it's stamped on her record. And she shall be treated as though she is positive at the time of birth. And although yes, just with the advent of the rapid test in labor, and the recent studies on that, which we're gonna get into later, later, yep, it might, you might be able to fight against that.

So later, we'll talk a little bit about a rapid test. And that I think, we're going to be talking about how that's a very viable option. But we're for the purposes of this discussion, because especially in the United States, the rapid test is extremely seldom utilized, we're going to be talking about just the regular GBS test. So the first important thing to understand is that diagnosis, when you get that test is going to stay with you through your birth, you can assume that if you're an exception, great, but it is safe to assume that. So Trisha, why don't you just tell us all how the test is done first at that 35 to 37 week mark.

So the test basically consists of getting a swab culture of the vaginal and rectal bacteria. So it goes up in the vagina and into the rectum quick swab. You can actually do this yourself. Or you can have your provider do it. But I think we've talked about this before you're a little bit at risk. If you have your provider do it and also getting a vaginal exam, which you don't need 36 or 37 weeks. Wait, they can do that during a GPS test.

So usually what happens is it's like well, we're gonna do your GPS test today. So why don't we get you on the table, put your feet in the stirrups, and we'll just check your cervix while we're doing the test.

Okay, so just be aware that they don't need to accompany each other you can say just to the GBS test and I don't want a vaginal or to avoid it all in you know, avoid taking your pants off and getting up on the table. Just do the test yourself. Just do they need support that? Yeah, absolutely. So you just go hand them the Q tip they hand you

the swab, you go into the bathroom, you swab yourself and hand them back the test kit.

You're thinking in terms of midwives probably more than obstetricians, don't you think?

I think you can do this in your OB office too. I think you can say just ask to do the GBS test yourself. All right. Cool. Because it's it's very simple and it does not require being on a table.

Well, what I like about that is there if that's happening there, they're trusting women. It's a it's a ludicrous concept for another person to trust you doing anything with your own body, but that is what it feels like they're trusting women. To do this. When I when I switched from an obstetrician to the midwives. In my first birth. I remember they said okay, you can go into the bathroom and weigh yourself and do your own urine test. And I remember thinking, Oh, you like you're trusting me to what a concept to trust me to report accurately my weight and do my own urine test and I loved that feeling of responsibility, but I didn't realize like that could extend to Gbs tests, and I'm very happy to hear it.

Well, we should definitely get some input from our audience on how many people have been offered to do their GBS test themselves or, or not. So let's do that. Test back to the test. So the the most common way to test for GBS is through vaginal and rectal swabbing early on in pregnancy when you do a urine sample they also test for GBS in your urine. Two to 7% of women will have test positive for GBS in their urine if you test positive for GBS in your urine you are considered to be a high colony count high have a high colonization of GBS and therefore you are considered positive all the way through and they won't even do a vaginal test at 3637 weeks and they don't treat women during pregnancy for that do they? Know I had one client years ago, a few years ago who was and I was stunned by it. And she said she tested positive at the beginning of pregnancy. And she's been on antibiotics for whole pregnancy. And I was astonished and I've never heard of it, read about it. It's not an ongoing risk factor to your baby, it's really something that has to be managed during the birth alone.

Right, so So what they're assuming what they're assuming if they're treating you with antibiotics throughout pregnancy is that your baby's at risk of getting infected all throughout your pregnancy, that that risk of the ascending infection into the uterus as possible with your bag of water and tech. Now, there may be some providers who believe that's true, but I don't think that there's any evidence to support that and there certainly is risk of being on an antibiotic throughout your entire pregnancy. And because in the case of GBS in the urine, it's a lot less likely that your GBS status is going to change throughout pregnancy. And that's why when you test positive in the urine, you're considered positive all the way through and they're gonna want to start antibiotics. As soon as you're in labor.

So there are problems with the test. It takes about a couple of days for the results to come in at least 48 hours. That is made potentially a problem with what the tests but there's there are bigger problems with the tests. I'm gonna talk about what they are.

There are definitely problems with the GBS test, it's not a perfect test. The issue is that as we mentioned already, GBS can come and go. There are false negatives with the tests and there are false positives so you can test positive at the time of your screening. But in those cases of women who test positive at the time of screening, when they actually go into labor, 16% or so of those women will actually be negative at the time of birth. And conversely if you test negative, about 9% of those women who are tested negative at their screening will be positive at the time of birth. And interestingly, two thirds of the cases of early onset disease of GBS or GBS infection in the baby are in false negative women. So women who were tested, tested negative ended up with their babies getting sick, two thirds of the cases are of that type.

So just to just to reiterate a little bit, if you are tested positive, then your provider will be recommending that you receive periodic courses of intravenous antibiotics during your birth, typically a course of antibiotics every four hours, but I've heard of providers who who deviate a little bit from that protocol But most women get one or two potentially three courses throughout their labor. And a lot of women don't love that. And they're a little bit bummed about it. Because no one wants to give unnecessary antibiotics, the risk of your baby contracting GBS we're going to get into but it's very low. So to for all women to receive it, it's a little bit of a downer sometimes, because you know, you don't want to give unnecessary antibiotics if your baby doesn't really need it. But the the more interesting side of this is for the women who test negative, as we said earlier, it really doesn't come up again. But 9% of them will actually be positive at the time of birth, and no one's thinking about it, no one's addressing it, no one's doing anything about it. And we're not saying that they should, because the only solution would be if we don't have a better test in the meantime, to give absolutely everyone antibiotics during birth, which would be ridiculous. But it is interesting how very imperfect this test is and how we're treating it like it's this absolute science, and putting everyone into these boxes. And there's a lot of flaws on both sides and risks on both sides.

I think the most important point there is that of two thirds of the babies who are getting sick with this, which is what we're trying to prevent babies getting early onset disease, if two thirds of those are born to mothers who tested negative then our screening system isn't working that well. Right. The other thing I want to say just a point on getting the antibiotics and labor is that also if you don't get the antibiotics, at least if you don't start them at least four hours before your baby is born. Their effectiveness is dramatically decreased, like by at least half.

So that's an important point. Let's just stop for a second and talk about that. So let's say a woman goes into labor, she gets to the hospital at noon, she's been in labor for a couple of hours, we're going to talk about risk factors. But what should happen is whether it's within four hours of her membranes being released, and we'll get into risk factors later, but Trisha, what if her membranes are intact? She gets to the hospital and has the baby right away before they can give a course of antibiotics? Is it recommended to test the baby? Or do they just basically leave the mom and baby alone and keep an eye on the baby?

They typically just watched the baby monitor the baby if she didn't get the antibiotics. But that could vary from hospital to hospital. I'm not entirely sure.

Yeah, cuz I think some say well, then we have to take the baby away for testing. And I think that's the big threat. That's the big thing everyone's worried about?

Well, yes, the that's the concern. Also, when you go in with unknown GVS status is that they are going to be more on top of monitoring your baby, which may mean taking the baby away for testing more often.

And this puts women in a really difficult position when they want the antibiotics because everyone is getting that advice if they're birthing in a hospital, which we're presuming right now, to get to the hospital as late as possible. And now this is like a great if I get there too late, and they haven't had a chance to give me the antibiotics. And I have the baby too quickly. And no one wants that vibe and that energy to not want to have the baby when they're having that urge. And not everyone wants the baby to come pretty, you know, in good time. But like then the question is, what are they going to do? And how are they going to treat this baby after the baby is born if they haven't had antibiotics?

Right. And I think the important thing to remember at least for the mother from her perspective is again that if your water is not broken for an extended period of time and your baby does come really quickly and you didn't get a chance to get the antibiotics, your baby's at risk of skin colonization with GBs but very unlikely that they're going to have the more systemic through the lungs, that you know that that's the risk for getting for the baby getting sick with the GBS infection, not just getting it on their skin as they come through. So most of the time, if your baby's born quickly and your bag of water was not ruptured for a long period of time, people are a lot less worried about it.

So let's talk about the risk of what happens if the baby contracts and how dangerous is it? How likely is it?

Right so the question that everybody wants to know is should I should I get tested? Should I be treated? What's the risk to my baby like that's the ultimate question is How likely is my baby to get sick and to get sick and or die from GBS infection? So fortunately, most healthy full term babies will not get sick even though many of them can get colonized. If you test positive, that does not mean that they're going to get sick. The risk of a baby developing a serious life threatening GBS infection is about one to 2%. The mortality rates the number of babies that actually die from GBS infection is about two to 3%. For full term infants. It's much higher for preterm infants.

It's two to 3% for preterm infants who have contracted a systemic infection full term. If 100 Babies are infected with early onset GBS, two to three of them will die two to 3%

So out, we're not talking 100% of babies in general, we're not talking about that we're talking first about 100% of babies who are untreated for GBS so that in that category, we have women who tested negative but actually ended up being positive at birth, whether they knew it or not. And we have women who tested positive and declined the antibiotics, which is a small number probably in the US because most women get the antibiotics I've noticed, but that's what we're looking at babies who were exposed to Gbs at birth, and they were coming from mothers who are not treated with the antibiotics, one to 2% of those babies will contract what's called GBS early onset disease, that's when they have that systemic infection, Trisha was talking about, and two to 3% of those babies will die. Okay, so if I'm understanding these numbers correctly, what that's telling us is of 10,000 babies born to mothers with GBs infection without antibiotics, one to two of them will die. That's the bottom line. That's the takeaway, because we just did this is the percent that will contract it. This is the this is the percent that won't recover. And that number comes out to point 015, where I considered it one and a half percent, because we said it was one to 2%. That's what the data shows. So I considered it 1.5%. Now, what we're also seeing is when women are treated with antibiotics, that risk of death, that risk of mortality is reduced by 80%.

That's right. But it's done those Cochrane Reviews that are considered invalid because they just don't have good data collection. But that's the number most people

are working on. And it's the only number anyone has Yes, what you're saying. So it's not great data. Why is it not great data?

Because it was done in the 90s when they just weren't collecting data in in the most
who's saying it's not good data is what I'm asked. The Cochrane

Cochrane review says that those statistics areinvalid. So we have no other statistics to look at.

There is no current good research on GBs. Okay, a few midwives I know don't ever treat with antibiotics. And this has not been their protocol to use antibiotics. It is extremely unlikely that a baby will die from this but the risk does exist and that's why we want to take it seriously enough to look at these things. But when babies are born to moms with GBs, most of them will not get GBS infection. And there are reasons for that. Now some whale again, that's why we're talking about this and that's why this matters. But why wouldn't baby contract it? Well, first of all, one of the risk factors of a baby contracting it is if they're born prematurely because their own immune system can handle the GBS as we learned in about 9998 99% of cases they won't contract anything that's because of their own good immune system. That's one reason why they might not contract it.

The mortality rate for premature babies is many fold higher.

Okay, so the numbers we just provided were just for full term babies and it is much higher for premature babies because of their immune system. Yes, in a GBS+ woman giving preterm birth, it is almost like it just an absolutely you're going to take antibiotics.

Makes sense to it. Yeah. Yeah. Okay. And then another risk factor. We you mentioned it, you alluded to it earlier, it has to do with ruptured membranes, the longer the membranes are ruptured. The longer they're at before the birth, the longer that baby is exposed to the bacteria. I believe ACOG says 18 plus hours is what they're looking at. Yes, yeah. So if you're if you have had your membranes released in labor, and you haven't had the baby within 18 hours of the release of your membranes, that is now another risk factor for GBS, meaning your baby is now more likely to contract it than if you were to have your baby within that 18 hour window, again, makes antibiotics more reasonable than not.

If you develop a fever and Labour's another one as well as having GBS in the urine, that's considered a high risk factor because your colonization count is considered to be so much higher.

So maternal fever, there definitely is an infection going on. So we want to address that. And then as you said, if it's in the mother's urine, she has a particularly high colonization of GBS again making the baby more likely to contract it. So these are some really important risk factors to be aware of if you do test positive for GBS so let's let's talk about some risk factors for testing positive what makes one woman tests positive for GBS and one woman not. So the first thing is young age. Younger women under 20 years of age tend to test positive more often Women who have multiple sexual partners because multiple sexual partners are going to change up your vaginal flora. Women who have chronic hypertension or pre existing diabetes are more likely to test positive. Interestingly, women who use tampons regularly are more likely to test positive tobacco use oral sex, male to female oral sex is more likely in poor hygiene.

Also, interestingly, these kinds of data this kind of data always frustrates me because I never make sense to me. But a study was done in the London area of 6000 women in 2019. And they found differences by race. And black women do test positive more than other races, I don't understand why we see things like this, it doesn't make any sense to me for black women. In this particular study of 6000 women 39.5% tested positive for GBS for white women, it was 27.4%. And for Asian women 23.3%. Either way, we're always looking for individualized care. And that's why the risk factors, I think, are the most important information we've given so far. Because even hearing mortality rates, it's somewhat comforting knowing that it's extremely unlikely, but every woman is worried about that risk. But still, we can only do so much with general statistics. But those risk factors, I think are the most important information we've given you today, if you actually have GBS and if you test positive, and you're in labor, you can now have the awareness to understand the likelihood that your baby will potentially be at risk. So if you go into labor at full term, and your memories, membranes are intact, you immediately can think okay, so far, so good. I don't have a fever, membranes are intact, no clock has started ticking yet on the membranes. I'm full term here. That is the kind of information we want you to take away from this so that you can make your own informed decisions along the way, because we can all look at statistics and studies all the time. And it's I think, I think it's a false sense of comfort and information. What you really need is how do you handle it? When you're in labor? What decisions do you make, that's why we look at risk factors.

And we didn't mention vaginal exams. And that actually doesn't really come up in the Data Pipe because it hasn't been studied. But we certainly know that there's an increased risk of infection or choreo, during labor with multiple vaginal exams, and intra uterine monitoring in labor is also associated with a higher risk factor for a baby to be infected with GBs. So that would be like the internal scalp. Fetal scalp electrode monitor, not fans of any way, measuring the strength of a contraction with an intrauterine pressure monitor, which sometimes is recommended.

I hate these interventions. But that's a good point, Trisha, because how many providers aren't willing to do those things because a mom tested positive, that would be the right thing for the provider to do. That's right. I don't believe that that's happening,

but they're already treating it with antibiotics. So it's probably not going to change how they manage the mother's birth. Right? Because but even the antibiotics are not totally effective. That's right can still contract. That's right. Especially if it's been less than four hours, but you're probably not having as many interventions, if it's been less than four hours between, you know, if you get to the hospital and your baby's born an hour later, you're not likely to have a lot of vaginal exams or any of these inter uterine monitoring. So but just overall, just think it's just important to say that, you know, the less that's going up and in the vagina, the less likely you are to have any type of ascending infection into the uterus. And that's important to remember. So I think the the overall takeaway here is that, in general, there's a very low likelihood that your baby is going to develop early onset GBS infection, even if you're positive, it's one to 2% chance of that however, the risk of your baby developing GBS infection without treatment is about five times higher. So that's a good takeaway.

I guess one question women have before we wrap up this regular episode is am I am I can I decline the antibiotics if I want? And I'd like to hear your and I'd like to hear Trisha if a woman decides to do that. What should she do instead? For example, we had we had Christina's birth story on our episode in I think it was February of last year might have been March of last year. And she shared a really extraordinary birth story of having GBS her providers wanted to induce her she called me crying from the parking lot of the emergency room and she said every cell in my body is telling me not to go into the hospital right now and and be induced because my membranes released and I have GBS and I put her in touch with My mentor, and she went to Boston and had this amazing birth a couple of weeks later with Nancy Waner. But Nancy didn't just say, yeah, the heck with it, we're not going to do antibiotics, Nancy said, Okay, when you drive back home to New York, you will not use a public restroom, I want you taking this much vitamin C, I want you she told her what to do to reduce the likelihood of infection. So I guess what we're saying is, if you do decline, the antibiotics, that is your right to do so. But you still have a responsibility to yourself, to carefully manage your birth and keep yourself infection free. So I would say if that's your decision, I wouldn't think in terms of being too casual about it. But do your research on how you can stay healthy and keep your immune system up. In the meantime, and reduce the likelihood of that happening. Of course, membranes being intact is a big part of as well, and natural sources of vitamin C are an outstanding way to have stronger membranes, though, that's no guarantee, I think we're gonna go into that and into the extended version, some of the things you can do to try to ensure that you don't test positive or if you do pass test positive to potentially be negative at the time of birth. But I would just add to that, that if you do test positive and you do decline the antibiotics, I would at least recommend following the risk based protocol for starting the antibiotics, if any of those things, any of those risk factors develop in labor, my personal recommendation would be to start antibiotics.

It's a risk benefit situation. And we already see the likelihood going up if those risk factors are present, that would be reasonable to get the antibiotics is what you're saying it's a reasonable choice.

I think it's the right choice.

Okay, well, I think we're ready to go deeper on this. But if you're here for the regular episode, we hope this was helpful. And for the full version, which is an hour long episode, head on over to patreon.com/down to birth show. And you will get the full extended version ad free plus all our other extended episodes and some other goodies over there. So head on over there if you'd like the full version of this episode, and otherwise, thank you so much for joining us. And if you have your own GBS questions or stories that you'd like to reach out with, you can always call us at 802438369680 to get down and with that, I think we're ready to dive deeper on this Trisha awesome so onward into a little bit more detail here.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.